Safe Surgery - Pre Op to OR Handoff

HARD STOPS: Pre-Anesthesia Assessment Document completed, H&P Completed (within 30 days and updated day of surgery), Completed Surgery/Procedure Consent, Completed Anesthesia Consent, Site Marking (if applicable)

Which department are you completing this survey for?

Name of the employee observed:

Patient MRN?

Safety Handoff Form utilized during handoff?
If not, give reason:
Was a face to face handoff completed?
If not, why?
Patient verified using two patient identifiers?
H&P Updated

Must be within 30 days and updated day of surgery
Surgery/Procedure Consent completed?

To be complete:

  • No abbreviations
  • Provider signature 
  • LAR signature 
  • Witness signature
For incomplete Surgery/Procedure Consent

Please check all that apply:
Anesthesia Consent completed?

To be complete:

  • No abbreviations
  • Provider signature
  • LAR signature
  • Witness signature
For incomplete Anesthesia Consent

Please check all that apply:
Pre-Anesthesia Assessment Document completed?
Site marking performed?